[Bean or blue rubber blue nevus syndrome. Presentation of 6 patients]

INTRODUCTION/AIMS

Bean or Blue Rubber Bleb Nevus Syndrome (BRBNS) is an uncommon disease characterized by multifocal venous malformations that predominantly affect the skin, soft tissues and gastrointestinal tract. Our objective is to familiarize the pediatric surgeon with this condition, promoting early diagnosis and seriated surgical treatment as therapeutic options. We have reviewed the diagnosis and treatment of 6 patients treated from 1993 to 2009.

MATERIAL AND METHODS

All the patients had a venous malformation (> 10 cm) that acted as a marker. After, characteristic skin lesions appeared as well as chronic anemia due to digestive bleeding associated to hypofibrinogenemia. Age of appearance of the anemic picture varied from 6 months to 7 years, it being more aggressive the earlier its appearance. The diagnosis of the disease was made by endoscopically. All the patients required transfusion with blood derivatives 5 to 25 times a year. Treatment was multidisciplinary: periodic transfusions in every case, endoscopic sclerosis in lesions that affect the colon or stomach and surgical treatment for lesions of the jejunum and ileum. In two of these patients, 23 and 46 lesions were excised, respectively. In the last year, the tendency has been to use enterotomy and fulguration with Argon.

RESULTS

The patients who have undergone excision of the digestive malformations have experienced a significant decrease in their transfusion needs. One female patient with miliary dissemination died.

CONCLUSIONS

BRBNS is a difficult to diagnose due to its low frequency. Treatment of gastrointestinal tract lesions is multidisciplinary, combining endoscopic and surgical techniques that decrease transfusions and improve the quality of life of the patients.

Telemedicine network physical connection design for remote areas. Case Baruta--El Hatillo

The telemedicine has increased mostly over recent years. Especially in developing countries where a high proportion of the population lives in rural areas or difficult to access. However it is successful implementation is closely connected with an appropriate design of the telecommunications network, part essential when deploying a network and the selection of appropriate communications technologies, realistic and sustainable according to the characteristics of the context in which it is deployed. This paper explain the situation of health centers in the municipalities Baruta and Hatillo in Venezuela, it proposes the design of a telemedicine network to allow interconnect the outpatient units with the referral hospital. Then it describes wireless technologies studied and finally it presents the entire design process of the network physical connection.

Interethnic differences in the accuracy of anthropometric indicators of obesity in screening for high risk of coronary heart disease

BACKGROUND

Cut points for defining obesity have been derived from mortality data among Whites from Europe and the United States and their accuracy to screen for high risk of coronary heart disease (CHD) in other ethnic groups has been questioned.

OBJECTIVE

To compare the accuracy and to define ethnic and gender-specific optimal cut points for body mass index (BMI), waist circumference (WC) and waist-to-hip ratio (WHR) when they are used in screening for high risk of CHD in the Latin-American and the US populations.

METHODS

We estimated the accuracy and optimal cut points for BMI, WC and WHR to screen for CHD risk in Latin Americans (n=18 976), non-Hispanic Whites (Whites; n=8956), non-Hispanic Blacks (Blacks; n=5205) and Hispanics (n=5803). High risk of CHD was defined as a 10-year risk > or =20% (Framingham equation). The area under the receiver operator characteristic curve (AUC) and the misclassification-cost term were used to assess accuracy and to identify optimal cut points.

RESULTS

WHR had the highest AUC in all ethnic groups (from 0.75 to 0.82) and BMI had the lowest (from 0.50 to 0.59). Optimal cut point for BMI was similar across ethnic/gender groups (27 kg/m(2)). In women, cut points for WC (94 cm) and WHR (0.91) were consistent by ethnicity. In men, cut points for WC and WHR varied significantly with ethnicity: from 91 cm in Latin Americans to 102 cm in Whites, and from 0.94 in Latin Americans to 0.99 in Hispanics, respectively.

CONCLUSION

WHR is the most accurate anthropometric indicator to screen for high risk of CHD, whereas BMI is almost uninformative. The same BMI cut point should be used in all men and women. Unique cut points for WC and WHR should be used in all women, but ethnic-specific cut points seem warranted among men.

Early age at first sexual intercourse and early pregnancy are risk factors for cervical cancer in developing countries

Early age at first sexual intercourse (AFSI) has long been associated with an increased risk of invasive cervical carcinoma (ICC). Age at first pregnancy (AFP) and ICC have been investigated less, although AFSI and AFP are strongly interrelated in most developing countries. A pooled analysis of case–control studies on ICC from eight developing countries with 1864 cases and 1719 controls investigated the roles of AFSI, AFP, and ICC risk. Age at first sexual intercourse, AFP and age at first marriage (AFM) were highly interrelated and had similar ICC risk estimates. Compared with women with AFSI ⩾21 years, the odds ratio (OR) of ICC was 1.80 (95% CI: 1.50–2.39) among women with AFSI 17–20 years and 2.31 (95% CI: 1.85–2.87) for AFSI ⩽16 years (P-trend <0.001). No statistical interaction was detected between AFSI and any established risk factors for ICC. The ICC risk was 2.4-fold among those who reported AFSI and AFP at ⩽16 years compared with those with AFSI and AFP at ⩾21 years. These data confirm AFSI and AFB as risk factors for ICC in eight developing countries, but any independent effects of these two events could not be distinguished.

fMRI activity correlated with auditory hallucinations during performance of a working memory task: data from the FBIRN consortium study

INTRODUCTION

Auditory hallucinations are a hallmark symptom of schizophrenia. The neural basis of auditory hallucinations was examined using data from a working memory task. Data were acquired within a multisite consortium and this unique dataset provided the opportunity to analyze data from a large number of subjects who had been tested on the same procedures across sites. We hypothesized that regions involved in verbal working memory and language processing would show activity that was associated with levels of hallucinations during a condition where subjects were rehearsing the stimuli.

METHODS

Data from the Sternberg Item Recognition Paradigm, a working memory task, were acquired during functional magnetic resonance imaging procedures. The data were collected and preprocessed by the functional imaging biomedical informatics research network consortium. Schizophrenic subjects were split into nonhallucinating and hallucinating subgroups and activity during the probe condition (in which subjects rehearsed stimuli) was examined. Levels of activation from contrast images for the probe phase (collapsed over levels of memory load) of the working memory task were also correlated with levels of auditory hallucinations from the Scale for the Assessment of Positive Symptoms scores.

RESULTS

Patients with auditory hallucinations (relative to nonhallucinating subjects) showed decreased activity during the probe condition in verbal working memory/language processing regions, including the superior temporal and inferior parietal regions. These regions also showed associations between activity and levels of hallucinations in a correlation analysis.

DISCUSSION

The association between activation and hallucinations scores in the left hemisphere language/working memory regions replicates the findings of previous studies and provides converging evidence for the association between superior temporal abnormalities and auditory hallucinations.

Working memory and DLPFC inefficiency in schizophrenia: the FBIRN study

BACKGROUND

The Functional Imaging Biomedical Informatics Network is a consortium developing methods for multisite functional imaging studies. Both prefrontal hyper- or hypoactivity in chronic schizophrenia have been found in previous studies of working memory.

METHODS

In this functional magnetic resonance imaging (fMRI) study of working memory, 128 subjects with chronic schizophrenia and 128 age- and gender-matched controls were recruited from 10 universities around the United States. Subjects performed the Sternberg Item Recognition Paradigm1,2 with memory loads of 1, 3, or 5 items. A region of interest analysis examined the mean BOLD signal change in an atlas-based demarcation of the dorsolateral prefrontal cortex (DLPFC), in both groups, during both the encoding and retrieval phases of the experiment over the various memory loads.

RESULTS

Subjects with schizophrenia performed slightly but significantly worse than the healthy volunteers and showed a greater decrease in accuracy and increase in reaction time with increasing memory load. The mean BOLD signal in the DLPFC was significantly greater in the schizophrenic group than the healthy group, particularly in the intermediate load condition. A secondary analysis matched subjects for mean accuracy and found the same BOLD signal hyperresponse in schizophrenics.

CONCLUSIONS

The increase in BOLD signal change from minimal to moderate memory loads was greater in the schizophrenic subjects than in controls. This effect remained when age, gender, run, hemisphere, and performance were considered, consistent with inefficient DLPFC function during working memory. These findings from a large multisite sample support the concept not of hyper- or hypofrontality in schizophrenia, but rather DLPFC inefficiency that may be manifested in either direction depending on task demands. This redirects the focus of research from direction of difference to neural mechanisms of inefficiency.

Health and economic impact of HPV 16 and 18 vaccination and cervical cancer screening in India

Cervical cancer is a leading cause of cancer death among women in low-income countries, with approximately 25% of cases worldwide occurring in India. We estimated the potential health and economic impact of different cervical cancer prevention strategies. After empirically calibrating a cervical cancer model to country-specific epidemiologic data, we projected cancer incidence, life expectancy, and lifetime costs (I$2005), and calculated incremental cost-effectiveness ratios (I$/YLS) for the following strategies: pre-adolescent vaccination of girls before age 12, screening of women over age 30, and combined vaccination and screening. Screening differed by test (cytology, visual inspection, HPV DNA testing), number of clinical visits (1, 2 or 3), frequency (1 x , 2 x , 3 x per lifetime), and age range (35-45). Vaccine efficacy, coverage, and costs were varied in sensitivity analyses. Assuming 70% coverage, mean reduction in lifetime cancer risk was 44% (range, 28-57%) with HPV 16,18 vaccination alone, and 21-33% with screening three times per lifetime. Combining vaccination and screening three times per lifetime provided a mean reduction of 56% (vaccination plus 3-visit conventional cytology) to 63% (vaccination plus 2-visit HPV DNA testing). At a cost per vaccinated girl of I$10 (per dose cost of $2), pre-adolescent vaccination followed by screening three times per lifetime using either VIA or HPV DNA testing, would be considered cost-effective using the country's per capita gross domestic product (I$3452) as a threshold. In India, if high coverage of pre-adolescent girls with a low-cost HPV vaccine that provides long-term protection is achievable, vaccination followed by screening three times per lifetime is expected to reduce cancer deaths by half, and be cost-effective.

Clinical pharmacokinetics of ferric natural protein in iron-deficient females

Although iron therapy is very common, few studies have assessed iron absorption or iron kinetics in general, particularly with Fe(3+). This was the primary objective of this study, with assessment of tolerance as a secondary objective. Eight nonsmoking iron-deficient females without other associated pathologies, with an average age of 21.62 +/- 1.69 years, were studied. The diagnosis of iron deficiency was established by determination of sideraemia (28.7 +/- 13.5 microg/dl), iron binding capacity (380.5 +/- 70.2 microg/dl) and ferritin (5 +/- 1.4 microg/L) on the prestudy visit. The women remained in the Phase I Unit during days 0, 1, 2 and 3 of the study. A serum iron concentration curve was obtained daily from blood samples drawn at 0, 1, 2, 4, 6, 8 and 12 hours postdose. Therapy with ferric natural protein (ferrimannitol ovoalbumin) 40mg twice daily was started on day 1 of the study and continued for 30 days. The following parameters were evaluated: area under the curve (AUC(0-12h)), peak iron concentration (C(max)) and time to reach peak concentration (t(max)). Serum iron concentration-time curves were practically flat on day 0, but showed an increase following ferric therapy (Friedman, p < 0.05), confirming the usefulness of the postabsorption test and good absorption of ferric iron (Fe(3+)). The increase in AUC (314.65 +/- 67.9 to 1174.44 +/- 1071.8 microg/dl.h) and C(max) (49 +/- 24.4 to 146 +/- 101.9 microg/dl) from day 1 and the correlation between both parameters (r(2) > 0.85, p </= 0.008) supported the use of either parameter. The t(max) ranged from 4 to 6 hours. Ferric therapy was well tolerated by all patients. This study shows that ferric iron contained in this preparation is well absorbed and provides a satisfactory method for evaluation of iron absorption.